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Women and substance use: epidemiological issuesPRATIMA MURTHY

PROFESSOR OF PSYCHIATRY

CENTRE FOR ADDICTION MEDICINE

NIMHANS

2Format of Presentation

1. The Indian Scenario

2. Global Scenario

3. Patterns of substance use

4. Drivers of substance use

5. Biology and gender

6. Substance use and reproduction

7. Substance use among elderly

8. Substance use in custodial settings

9. Co-morbidity

10. Treatment

31. The Indian Scenario

Women as victims of substance use to women as substance usersCase ReportsFocused thematic studies Reports focusing on women

4Epidemiological studies 1970’s – 1990s

Negligible substance use apart from tobacco

Alcohol use about 3% among women and illicit drugs

and psychotropic use between 0.1 to 0.3%

1990’s: ever drug use among 6-8% of women

Substance use among women difficult to pick up and

study in traditional surveys

5UNODC – A tale of three studies

Burden on Women due to drug abuse by family members (Shankardass et al 2002)Study of Women Substance Users and Sex Trade Workers In India (Kapur et al 2001)Rapid Assessment Survey (Kumar

2002)

6These studies chartered course ahead

Several limitationsNevertheless, raised issues pertaining to indirect and direct impact of substance use on womenHighlighted need to examine issues against the background of social disadvantage and subordination Highlighted need for a shift from a purely individual, single-cause linear model to a multi-cause interactive model in understanding addiction.

7Interacting factors leading to drug use among women

Murthy 2002

8Women Substance users (FSUs) –SWAHA

N=1865

9Substance use last month (FSUs) I 49 SWAHA

Rank orderHeroin (25.3%)Dextropropoxyphene (18.3%) Sleeping pills (15.7%)Cannabis (15.4%)Cough syrup (8.3%)Buprenorphine (4.2%)Solvents(3.1%)

Alcohol use reported by 67.5% of FSUs

Tobacco use reported by 75.7%

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Andhra Pradesh

Arunachal Pradesh

AssamBihar

Chhattisgarh

Delhi

Goa

Gujarat

Haryana

Himachal Pradesh

Jammu &Kashmir

Jharkhand

Karnataka

Kerala

Madhya Pradesh

Maharashtra

ManipurMeghalaya

Mizoram

Orissa

Sikkim

Tamil Nadu

Tripura

Uttaranchal

Uttar Pradesh

West Bengal

LakshadweepAndaman and Nicobar Islands

Punjab

RajasthanNagaland

Sites with FDU > 8%

RAS National Survey 04: 8%

H13 RSRA: 6%

Female Drug Users (FDU)

11.5%

16.9%

10.8%23.2%

9%

9.2%

33%

11Drug Use: With Present Drug Drug Use: With Present Drug Using Partner (9 sites) Using Partner (9 sites)

0

25

50

75

100

VES Kripa, Darj Krip, Imphal Shalom Bethesda Kripa,Nagaland

New Hope New Life Care

Ever Used with Present Drug Using Partner

In these 9 sites where the number of female sex partners having ever used drugs was found to be over the mean of 20%, a sizeable number of the respondents reported having ever used drug after marriage/ relationship with present drug using partner

12Number of Sexual Partners Number of Sexual Partners in Last 12 Months in Last 12 Months –– RSRARSRA

5921

2

8

10

0 to 1 partners 2 to 3 partners 4 to 5 partners>5 partners No response

In all the demonstration sites, sex with multiple

partners was reported in the past 12 months.

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Ever been tested for HIV Partner ever been tested

FSU (1774) NSUP(4200) FSU (1635) NSUP (4147)

N % N % N % N %

Yes 595 33.5 797 19.0 320 19.6 674 16.3

No 989 55.7 3032 72.2 738 45.1 2470 59.6

Don’t know 122 6.9 224 5.3 475 29.1 802 19.3

No response 68 3.8 147 3.5 102 6.2 201 4.8

HIV testing (SWAHA)

14Violence – SWAHA

  N FSU  % FSU N NSUP  % NSUP  Odds Ratio

Any violence  1271 72.9 2804 68.5  1.2**

Type of violence (among those reporting violence)

Verbal violence  1270 96.9 2937 97.6  0.77

Physical violence  1187 90.5 2415 80.4  2.3***

Sexual violence  667  52.5 856 30.3  2.5***

Perpetrator of violence 

Partner/spouse  745  84.3 1103 81.1  1.2

Parents  186  21.3 249 18.7  1.2

In laws  104  12.1 201 15.2  0.8*

Friends  159  18.4 108 8.2  2.5***

Employer  89  10.3 64 4.9  2.2***

Police  240  27.7 123 9.4  3.7***

15Impact on Children (SWAHA)

Low female: male gender ratios among children, likely a grim reflection of persisting gender inequality in India

Greater levels of illiteracy and primary school drop out among FSU children

In some FSU homes other family members like grandparents assume parental responsibilities

Among NSUPs, despite paternal substance misuse, more children able to go to college

Emotional, academic and behavioral problems common and significantly greater in dual substance using households

Higher rates of tobacco and alcohol use, and emerging drug use

Substance use higher among sons than daughters in both groups

NSUP mothers have more concerns on all aspects of their children’s health and functioning than FSU mothers

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Feelings of worthlessness and suicidal attempts (I 49 SWAHA)

FSU NSUP OR

N % N %

Felt life was not worth living

during the last year

1218 66.6 2360 54.3 1.63***

Attempted to take own life

during last year

726 40.2 1286 29.7 1.54***

*** significant at p<0.001

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Violence

Emotional distress

Impoverishment

Qualitative interviews I 49 SWAHAFSU’s – double disadvantage

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I 49 SWAHA

19

I 49 SWAHA

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Murthy 2011

2. Global scenario

213. Patterns- The Closing Gap…NESARC study

• 2001 to 2002 NESARC, sampled more than 42,000 individuals.

• Rates of alcohol use/abuse /dependence were smallest for younger cohorts

• 1950s male/female ratio of initiation in the 10- to 14-year-old age group was 4:1 - 1990s it was 1:1

– Greater proportion of women working outside home.

– Lesser proportion of women bearing children.

– Changing socio-cultural roles.

223. Prevalence

Alcohol – 5-8% (Genacis 2005)

Tobacco – 20% (GATS 2010)

Other drugs- Focused thematic studies

Prescription drug use

Hospital data (Opioids, other prescription drugs)

Bangalore Mall study- half the respondents were female(Nattala et al 2015)

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Lal et al 2015

3. Patterns and Prevalence

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Lal et al 2015

254. Drivers

265. Gender difference in Biology

Gender differences in neural process and behaviourNeuroactive steroidal hormonesDifferences in metabolismDifferential systemic effectsParticular effects on heart and nervous systemGender specific risk

276. Fetal alcohol spectrum defects

Ethanol may interfere with fetal development causing abortion, fetal death, premature birth, low birth weight, abnormalities in mental and physical development, somatic alterations. The teratogenic effects of alcohol are globally defined as fetal alcohol spectrum disorders (FASD) and the fetal alcohol syndrome (FAS) is the worst manifestation.

Fetal damage is not dose-related and may occur even at low levels of maternal alcohol intake, especially if ingested in early pregnancy.

28Fetal alcohol spectrum disorders

Most important preventable cause behavioural dysfunctionNOFAS – Range of deficits (physical, mental, behavioural & learning disabilities) seen in persons whose mothers consumed alcohol when pregnant with them.ARBD – Alcohol related birth defectsARND – Alcohol related neurodevelopmental disorderFAS – Fetal Alcohol syndrome

(Nayak et al 2008)

297. Elderly and substance use

Physical risk factorsMale sex (for alcohol), female sex (for prescription drug)Caucasian ethnicityChronic pain, Physical disabilities or reduced mobilityTransitions in care/living situationsPoor health status, Chronic physical illness/polymorbiditySignificant drug burden/polypharmacyPsychiatric risk factorsAvoidance coping stylePrevious and/or concurrent SUDPrevious and/or concurrent psychiatric illnessSocial risk factors (Affluence, Bereavement) Kuerbis et al 2014

Low in elderly women in India (Nadkarni et al 2013)

308. Substance use among women in correctional settings

17.9% of women prisoners reported use of tobacco in some form. This is marginally more than the prevalence of tobacco use among women in Karnataka (15.2%-figures for 2001). Chewing tobacco was more common among women (12.7%) compared to smoking (5.1%). 3 % used alcoholAnonymous urine screen in 60 women

30% screened positive for one or other drug

13 (22%) were positive for Benzodiazepines

3 (5%) for cocaine

2 (3.3% for opioids/amphetamines)

1 for cannabis

319. Co-morbidity

Mood and anxiety disorders- Lifetime rates of mood and anxiety disorders among individuals with substance use disorders

are significantly higher among women than men- Most common mood disorder among women with alcohol or drug use disorders was major

depressive disorder (15.4%) and the most common anxiety disorder was specific phobia (15.6%)The large majority (91%) of women with substance use disorders and a co-occurring Mood or anxiety disorder do not seek treatment Arch G Psychiatry. 1997;54:313–321.Eating disorder

- NCS-R estimated that rates of lifetime alcohol use disorders occurred in up to 34% of individuals with EDs, which is significantly higher than rates of alcohol use disorders in the general populationPrevalence of PTSD is 1.4 to 5 times higher compared to those without substance use disorders

…..Lowenson and Ruis, 5 th edition, 2010

3210. Course, outcome and treatment related issues

TelescopingTerm to describe an accelerated progression from the initiation of alcohol to the onset

of dependence and related medical complications.

Consistently observed across the world

more severe clinical profile (eg, more medical, behavioral, psychological, and social

problems) than men, despite having used less of the substance and for a shorter period

of time compared with men.

Medium interval first drink to dependence is 3 0 years for women and 3 6 years for men (Dawson 1996)

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34Treatment characteristics

Women’s only facilities and those with child care facilitiesInfluence length of stay, but not treatment completionService combining mental health and substanc use improve treatment completionBest response however is with women’s only programmesFlexible program, friendly staff, women’s only spaces, home visits, childcare improve treatment continuationNetworking important

Ashley et al 2003, Brady et al 2005, Murthy 2008,

35Treatment related issues

Systemic barriersStructural barriersSocio-cultural and personal barriersQuality of therapeutic relationship, Stigma and discrimination from health care system, Support needs, and Informational needs (Thomas et al 2017).

36Qualitative interviews

Thomas et al 2017

37Outcome

From complete loss to follow-up (Kamath and Murthy 1998) (Varghese et al 2014) to relatively better outcome if retained (Nebhinani et al 2013)No of life problems and number of supportive relationships good predictors of outcome (Macdonald 1987)

Mental illness related to poorer outcome (example- risk of relapse in depressed smokers doubled)

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You can tell the condition of a nation by looking at the status of its women

Pandit Jawaharlal Nehru

Long-term investments in the role of women as full and equal citizens-through education, economic, social, and political empowerment-will be the only way to deliver sustainable improvements in maternal and child (nutrition), and in the health of women and children more generally. Richard Horton The Lancet 2008